00-form_pendaftaranujianpkl.docx
TRANSCRIPT
KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGIUNIVERSITAS BRAWIJAYA
PROGRAM KEDOKTERAN HEWANJalan Mayjen Haryono No : 169 Malang 65145
Telp. +62341- 573642, Fax. +62341- 573642, 551611 psw 362http://www.pkh.ub.ac.id email : [email protected]
Form Pendaftaran Ujian PKL
NIM : ..............................................................
Nama MHS : ..............................................................
Judul : ............................................................................................................
..........................................................................................................................................
..........................................................................................................................................
Instansi PKL : ...........................................................................................................
Yang Akan Diselengggarakan Pada :
Hari : ………………………………………..
Tanggal : ………………………………………..
Pukul : ………………………………………..
Tempat Ujian : ………………………………………..
Nama Tim PengujiTanda
Tangan
Pembimbing 1 :
NIP.
Pembimbing 2 :
NIP.
Penguji :
NIP.
Mengetahui Malang, .....................................Wakil Bidang Akademik
Prof.Dr.Aulanni'am,drh.,DES NIP. 19600903 198802 2 001